Friday, February 25, 2005

Mortality and morbidity, with garlic bread on the side

On a recent weekday, I had the day off from the office job, so I went to the 7:30am trauma room conference. The conference is a review of a handful of the more interesting critical cases that came through the most acute part of our emergency department over the most recent week, grouped around a theme -- one week there will be two different head injury cases, for example, plus maybe a seizure case or another "altered mental status" case, if the general theme is level of consciousness. Conference takes place in a basement room that is all very hospital-white. There's coffee, and bagels show up at some point during the hour.

I like going when one of the a cases covered will be one I worked on, partly because I like to know how things came out for the patient. This can be good news or bad, of course. Speaking of head injuries, I'll never forget the one where someone I'd been there for was presented, and after the head CT and a report from our EM resident (assigned to Neuro at the time) came autopsy photos of the same massive brain clot, this time frankly visible within the exposed top of our former patient's cranium, with a report from the medical examiner.

I also go to conference because it's a chance to feel connected to the learning part of the process; to take advantage of the fact that I work at an excellent academic center, and I am encouraged to attend. I also like to imagine being able to call on these experiences later on, as a helpful memory. Not so much for clinical info, although surely I'm picking some of that up, too. I like the idea that because I have the chance to do this now, settings and situations like the conference won't ever be foreign to me, and thus less intimidating. It's part of the whole 'non-traditional' student thing. Many staff physicians are close to my age, but the residents are only younger than me by a factor that's about the same as how far behind them I am in education. Thus, I tend to gravitate to the resident part of the room.

Today I also stuck around for the med student lecture, something I do most days I attend the conference. As I said to the 3rd-year resident I was sitting next to, this is an unusual time in my training -- there would be no consequences at all if I decided to ditch the lecture, since I am "invited" and "encouraged" to attend the conference, but the lecture is pure bonus material. Somehow, this seems to work out to having the kind of attention span for medical education I fear I might be lacking later on, when things are going to get a lot more compulsory and/or graded.

It helped that while this lecture was unusually well-organized and presented in a more academic, true lecture-style way than some of the lectures I've attended, it was also really good. It amuses me to think that if I am asked to strap a blood pressure cuff to a patient's ankle in the next few weeks, I'll know exactly what's up. (Actually, I would have been able to suss it out on my own, strictly in terms of "what does that tell us?" But this way, I'll know it's because the resident and I attended the same lecture.)

Something I've never done was hang around after the lecture, for the Mortality and Morbidity conference. Having checked my voice mail, and knowing that lunch with the gf was not happening as planned, I was curious about what's next. The residents were not entirely sure at first, so I soon found myself with a very narrow window to decide if I would stick around. Turns out it was indeed M&M.

Would this be interesting? Totally. Educational and helpful? Sure. Would I just be there out of prurient interest? Not at all. Would it be okay for me to be there, or was this a doctor-only kind of thing? Uhhh.... well, I took a look around. The RN's had taken off already after conference, since they tend to have, y'know, lives, and of course nobody from other services was still around. But med students were still there.

One of the big things I've learned is that med students are nothing special. And I say that even as I make huge personal sacrifices in the fervent hope that I will be granted the opportunity to be one.

Some are of course wonderful, and brilliant, and it's obvious to see the future doctor just beneath the surface. Many are studious, well-intentioned young people, who with some time and effort will be great. Many are exactly what you'd think, if you watch a lot of Scrubs. Seriously, I have never had what I've felt was the requisite awe and respect for medical people; that's one factor that kept me from joining up earlier. But most of my experience has not yet shown I was wrong. Students are just regular ol' people... some moreso than others.

So it was staff, residents, med students, and me. But what the hell. The boss-doc who was running things saw me, we made eye contact, he gave no indication it was weird or inappropriate for me to be there. And it turned out to be really fascinating. For those who are unfamiliar, the "M&M" is the big meeting where we talk about what went wrong.

First was a discussion of things that get screwed up, in general, in the practice of medicine. There was a big long list that the group had been working its way down, over several weeks or months. The boss-doc presented some examples of issues culled from several years' worth of cases, pointing out where studies that had been read as normal were truly not, asking difficult questions of the residents, and applying hindsight to point out things not to be fooled by.

Then, specific stuff from the week at our hospital was presented, by various people who had been connected with the issues. None were huge problems, most were not even noticed by patients, but all were important because the team chose to make them important. Here's the situation, here's how it might have been prevented, and here's how we make sure it doesn't happen.

How come every industry, business, and institution doesn't do this?

From TV and film portrayals of the M&M, you'd think it was a big auditorium with stone-faced old guys frowning down at a trembling young doctor in the hot seat. It's actually a discussion peppered with horrifying but comical stories from 25 years ago, when the gray-haired sage who now runs the show was a skinny little geek prone to rookie mistakes just like anyone, and chances for newbies to demonstrate the ability to learn from mistakes during, and even prior to, their commission. It's the healthiest, most honest, most real-life-no-BS-helpful way to make things better I've seen.

And that's sad, because I've been in the business world for what, 12 years? "Continuous quality improvement" sounds great, guys. Thing is, we've been doing it since Hippocrates. (I commented to GeekSpice once, more than a few months ago now, that I had found the word "we" coming out of my mouth when referring to medicine, and the way things work in that world. I did it again, just a couple of paragraphs ago, when I said "our hospital." Yep, I'm committed, now.)

As M&M wound down, food was brought in. I was ready to go home, and really, the next thing on the agenda was prep for board exams. If all goes well, I'll be getting ready for my USMLE Step I board exams at this time of year... six years from now. So, not so practical. But hey, free food. So I stood in line, where I talked a little with some staff docs about an issue that the M&M had addressed, then ladled up some ziti that had a nicely zippy sauce, one good-sized meatball, and then sat back down. Dammit, board prep started immediately. I was trapped.

And then came the best surprise of the day. The way the oral part of the boards is done is extremely similar to the way my EMT class had been run, as we practiced cases for patient assessment. There is an examiner, who guides you through a scenario, and you need to verbalize what you would do, what you would look for, etc. Bedside manner counts, following the standard of care counts, doing the steps in the right order counts. There are things you need to do and things you should not do, to earn full points or avoid failing the scenario altogether. The scenario is timed.

One first-year and one second-year resident were being quizzed by a third-year, in front of the group. Staff offered comments and gave pointers about the way things are structured. Sitting in our seats, my friend the third-year and I whispered about the food and he (correctly) diagnosed the problem in about 15 seconds. Me, I wasn't ready to go that far, but I knew what to do. I was shocked to find that not only would I probably not kill this imaginary patient, I might actually get a decent score on this scenario.

Now, this in no way means I would not wet my pants (figuratively or literally), if faced with a real situation. It doesn't mean I'm as smart as an intern. It just means I am on the right track, and the preparation I have done so far will directly relate to what I will be doing later. As someone who is racked just about daily by a very reasonable-sounding inner voice that questions the wisdom of all this, I appreciated the boost.

This is long enough, so I'm signing off, but that reminds me -- sometime I need to talk about that EMT class, and the imaginary patient I killed in one of those scenarios. She's the only one I've lost so far.

And I still think that even if I had asked about it, she might have denied taking the damn Viagra.

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